Sandi Lam, MD, MBA (left)
Division of Pediatric Neurosurgery/Department of Neurosurgery
Texas Children’s Hospital/Baylor College of Medicine
Baylor Center for Ethics and Health Policy
Pediatric Neurosurgery and the Health of Children
Once again, policymakers are debating ways to reform the U.S. health care delivery system, and over the coming weeks, Congress and the Trump Administration will be considering legislative and executive actions to modify the Affordable Care Act (ACA). For pediatric neurosurgeons, subspecialty surgical care is directly linked to pediatric health care delivery. High-quality, safe neurosurgical care for children, requires dedicated infrastructure as well as the collaborative services of pediatric medical/surgical specialties. The well-being of the entire family is critical, as over 98 percent of pediatric discharges are to home.
Health coverage-related disparities in access and clinical outcomes are well-described in pediatric surgical subspecialties. The optimal health care system is the subject of discourse, but all can agree that we must provide care for our littlest and most vulnerable patients. While the Medicaid program has recognized shortcomings (including low reimbursements, high administrative burden and extended payment wait times), the reality is that Medicaid provides needed access to health care for lower-income families and children, especially children with special health care needs.
Understanding the potential implications of repealing and replacing the ACA and restructuring Medicaid — which accounts for 17 percent of national health expenditures and serves children and families, people with disabilities, and individuals in long-term care — needs to be part of this discussion.
Why Does Medicaid Matter to Children?
Medicaid is jointly funded by states and the federal government. It covers 74 million people, including 30 million children. Medicaid provides insurance coverage for just a little less than employer-based plans (48 percent of children in the U.S. are covered by employer-based insurance, while 39 percent are covered by Medicaid.) In some states, over 50 percent of the pediatric population is covered by Medicaid. (For a Medicaid pocket primer, click here.)
In addition to providing coverage for low-income families, Medicaid and the Children’s Health Insurance Plan (CHIP) provide coverage or fill coverage gaps for children with complex medical conditions. The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit in Medicaid provides access to preventive services and other essential care, and 76.5 percent of pediatricians accept new Medicaid patients. An estimated 1 million children are covered in the marketplace among the 20 million Americans who have gained health insurance coverage with the ACA. Many private plans in the marketplaces offer essential health benefits similar to EPSDT, though this may no longer be the case if health reform legislation under consideration becomes law.
Medicaid’s expansion under ACA was made optional by the Supreme Court’s landmark ACA decision. While targeted at the higher rate of uninsured adults, the ACA built upon Medicaid and CHIP programs, and a record number of America’s children (95.2 percent) now have health care coverage. Many children became insured as a consequence of increased parental awareness with the ACA, which is also referred to as the “welcome mat” effect. The Maintenance of Effort (MOE) provision requires states to maintain their current eligibility levels for children’s coverage in Medicaid and CHIP until 2019. The rate of uninsured varies significantly between states. States with the highest rates of uninsured include Alaska, Florida, Georgia, Oklahoma, and Texas; even in these states, the total percent of uninsured has decreased since 2013. The South is home to 38 percent of US children, yet account for 50 percent of the country’s uninsured children. One in five uninsured children now lives in Texas. While children had increased enrollments across age groups, racial categories, and income ranges, disparities persist. For example, Latino children are disproportionately uninsured. Children living just over the poverty line (100-200 percent of Federal Poverty Level) have the highest rates of uninsurance (6.8 percent).
Medicaid Recipients Rely on Children’s Hospitals
The practice setting of many pediatric neurosurgeons is that of children’s hospitals. These hospitals are at the core of health care delivery for the pediatric population, with teams of pediatric specialists often not available in other settings. Children’s hospitals constitute less than 5 percent of hospitals in the U.S., yet account for 35 percent of hospital days for children on Medicaid and 53 percent of hospital days for children with complex medical conditions, such as neurosurgical conditions.
Because of the small number of children’s specialty centers, each institution serves a broader geographic area than most adult hospitals. For families, particularly those with medically complex children, this geographic dispersion may mean traveling long distances or across state lines to meet specialized health care needs. For children’s specialists, this requires coordinating with multiple state Medicaid programs that reimburse at most up to 80 percent of the cost of care including Disproportionate Share Hospital (DSH) payments.
Recent policy efforts for Medicaid reform aim to cut costs, promote efficiency, and improve care for children. In the 114th Congress, the bipartisan Advancing Care for Exceptional Kids Act, or ACE Kids Act, (S.298/H.R. 546), which the AANS and CNS endorsed, was introduced. The ACE Kids Act creates a state opt-in for a national framework to coordinate care across state lines for children with medical complexity in Medicaid to improve quality while reducing costs.
Risks of Restructuring Medicaid Financing
Medicaid constitutes over 50 percent of all federal funding to states. Proposals for restructuring Medicaid include block grants and per capita caps limiting federal contributions. Restructuring Medicaid financing may result in a shift of costs and risk to states, potentially removing guarantees of coverage, and increasing the number of uninsured children. It would also put pressure on other state-funded programs (such as education, child care and welfare), which could weaken the ability of states to respond to public health crises and economic downturns. Such limitations further strain a safety net that is already stretched. Barriers for children to access preventive, primary and specialty care can increase health care costs and utilization in the long run. (For more information on block grants and per capita caps, click here.)
Role for Neurosurgery: Be a Part of the Solution
Children with neurological complex chronic conditions require a disproportionately large amount of health care resources (Figure 1). These high-resource utilization groups can be targeted for innovation in care delivery models.
Innovative solutions should aim to improve care, increase efficiency, achieve savings and bend the cost curve with an ever-better Medicaid program. Medicaid is a lifeline providing coverage for a significant portion of children in the U.S. In the limited scope of this piece, directions for the future are framed within the current system. Barring the creation of an entirely new health care system, it is not feasible to reduce financial support to a program and expect it to outperform. We can, however, learn from best practices and high performers. A framework that supports the sharing of national data, clinical standards, and quality measures designed for children, could accelerate implementation of effective and efficient care within Medicaid. The bipartisan ACE Kids Act is certainly a step in the right direction.
In light of the current national debate, this is a critical time for neurosurgeons to take an active role in reshaping health care policy. With our experience in the treatment of complex patients, incorporation of technology, and leadership of surgical/medical teams, neurosurgeons are uniquely equipped to help address much-needed innovation in health care delivery. Let’s rise to the many challenges in health care and be part of the solution.